Opinion
Cause No. IP 99-0892-C-M/S.
October 25, 2000.
ORDER ON MOTION FOR SUMMARY JUDGMENT
This matter comes before the Court on defendants' Nyhart Company, Inc. ("Nyhart"), ELSA Corporation ("ELSA"), and ELSA Corporation Health Plan (the "Plan") motion for summary judgment on plaintiff Cheryl Parker's claim for benefits. The Court has fully considered the parties' arguments and, for the reasons discussed below, GRANTS defendants' motion for summary judgment.
I. FACTUAL BACKGROUND A. THE ELSA CORPORATION EMPLOYEE HEALTH PLAN
Parker was an employee of ELSA Corporation in Elwood, Indiana. The company maintains an employee welfare benefits plan — the ELSA Corporation Employee Health Plan (the "Plan") — which it established pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"). The Plan provides medical, prescription drug, dental, and weekly income benefits for eligible employees and their dependents who qualify as Covered Persons in accordance with the provisions of the Plan and ERISA. Stmt. of Material Facts ¶¶ 1-2. ELSA employees receive a copy of the Summary Plan Description ("SPD") at the commencement of their employment. Id. ¶ 3.
The Plan Supervisor, Nyhart Company, Inc. ("Nyhart"), agreed to "Process claims for benefits, on behalf of the Plan, and pay from the fund account benefits due under the Plan. Processing shall include determining the Covered Person's eligibility for the benefits claimed, based upon the data provided by the Employer, and, if necessary, investigating the claim." Id. ¶ 4.
The Plan provides for a short-term disability benefit, called a Weekly Income Benefit. In relevant part, the Plan provides:
6.01 Weekly Income Benefits
(Elwood Group Employees Only)
1. Disability Waiting Period
Injury 0 days
Sickness 7 days
2. Weekly Income Benefit Amount 60% of Earnings, to a maximum benefit of $600 per week
(C) Maximum Benefit Period
Injury 26 weeks
Sickness 26 weeks
Total Disability
As a result of Sickness or Injury:
1. The Participant is unable to perform each of the material duties of his regular occupation and is not performing work of any kind for wage or profit;
2. The Dependent is unable to perform each of the usual and customary activities of a person in good health of the same age and sex.Id. ¶ 5.
The Plan further provides as follows:
3.16 Disability Waiting Period
The period at the beginning of a period of Total Disability for which no Weekly Income Benefits are payable under the Plan.
3.24 Employer
ELSA Corporation, Elwood, Indiana, or any successor corporation which adopts this Plan.
3.41 Plan Administrator
The person designated by the Employer to administer the Plan as provided in Article XIX. The Plan Administrator is the Employer.
3.42 Plan Supervisor
The firm designated by the Plan Administrator to provide claims administration services in connection with the operation of the Plan, and any other services requested by the Plan Administrator. The Plan Supervisor is the Nyhart Company, Inc., Indianapolis, Indiana.Id. ¶ 6.
In addition, the Plan provides as follows:
WEEKLY INCOME BENEFITS
On receipt of satisfactory proof of claim, the Plan will pay Weekly Income Benefits.
6.01 Benefit. The Weekly Income Benefit Amount will be paid if the Employee becomes Totally Disabled while a Covered Person as a result of a Sickness or Injury. Benefits will be paid while the Employee is Totally Disabled and under the regular care of a Physician, but not beyond the Maximum Benefit Period. Benefits will begin following the Disability Waiting Period. The Weekly Income Benefit Amount, Maximum Benefit Period, and Disability Waiting Period are shown in the Schedule of Benefits.
6.02 Payment of Benefits. Benefits will be paid promptly following receipt of satisfactory proof of loss, but not more frequently than weekly. Benefits payable for a partial week of Total Disability will be paid at the rate of 1/7 of the Weekly Income Benefit Amount for each day of Total Disability.
* * *
6.04 Termination of Benefits. Benefits will terminate on the earliest of these dates:
1. The date the Employee is no longer Totally Disabled.
2. The date the Employee is no longer under the regular care of a Physician, unless he demonstrates that further medical care is not expected to improve his condition.
3. The end of the Maximum Benefit Period.
Id. ¶ 7.
With respect to administration, the Plan provides:
ADMINISTRATION
19.01 Powers and Duties. The Plan Administrator is the named fiduciary of the Plan and has the power and duty to do all things necessary or convenient to effect the intent and purposes of this Plan, which are not inconsistent with any of its provisions. Not in limitation, but in amplification of the foregoing, the Plan Administrator shall have power and duty to:
. . . .
A. Construe the Plan, which construction shall be final and binding.
B. Correct any defect, supply any omission, or reconcile any inconsistency in the Plan in such manner and to such extent as it shall deem expedient to effectuate the Plan.
C. Determine all questions that may arise under the Plan including questions of eligibility to participate in the Plan and the benefits provided by the Plan.
D. Delegate to such other parties as are appropriate pursuant to ERISA all or any part of the responsibilities specifically required of the Plan Administrator under the terms of the Plan.Id. ¶ 8.
Finally, the Plan further states as follows:
Payment of Claims.
. . . .
If a claim is not paid in full, the Plan Supervisor will furnish notice to the claimant specifying the reason and describing any additional information required to perfect the claim. Upon written request by the claimant, if made within 60 days after notice or denial is received, the Plan Administrator will review the claim in question and give a final written decision on the review within 60 days or, if needed information could not be obtained, within 120 days, after such request for review is received. Id. ¶ 9.
B. PARKER'S CLAIM FOR DISABILITY BENEFITS UNDER THE PLAN
On October 23, 1995, Parker filed a disability claim. Id. ¶ 10. Her last day of work before she allegedly became disabled was October 13, 1995. Id. ¶ 11. Dr. Steven Berghofer, a general practitioner and Parker's family doctor, attached a statement to the disability claim identifying her diagnosis as chest wall syndrome and bronchitis. Id. ¶ 12. Dr. Berghofer indicated that Parker was totally disabled, but that he expected a fundamental or marked change in the future. Kim Tolliver Affidavit, Ex. 1. Dr. Berghofer further indicated that Parker would recover sufficiently to perform her duties in one month. Id. Upon receipt of Parker's claim, ELSA referred the claim to Nyhart for claims administration. Stmt. of Material Facts ¶ 13.The Plan initially granted Parker's claim and sent her a check for $581.32 to cover the one-month disability. Id. ¶ 14. On November 21, 1995, ELSA faxed Nyhart an additional form from Dr. Berghofer that mentioned gastroesophageal reflux disease in addition to chest wall syndrome, and stated that Parker would be off work until she was reassessed in two weeks. Id. ¶ 15. The next day, Nyhart specifically requested additional medical information from Dr. Berghofer. Nyhart supplied Dr. Berghofer with the Plan's definition of "total disability" and asked him to identify the necessity for the disability and the specific limitation which prevented Parker from working. Id. ¶ 16.
In a December 4, 1995 letter Dr. Berghofer raised questions about Parker's exposure to fumes and dust at work. Id. ¶ 17. Dr. Berghofer stated that Parker experienced increased chest pain when exposed to dust and strong fumes in the workplace, or after prolonged sitting, lifting, or exertion. As a result, Dr. Berghofer concluded that Parker "remains unable to perform each of her duties of her regular position, and qualifies as totally disabled as a result of sickness." Tolliver Aff., Ex. 6. After checking with ELSA, Nyhart informed Dr. Berghofer that the ELSA plant operations had met and exceeded OSHA clean air standards, reiterated its request for medical records for all dates of service from October 12, 1995 to the present, and requested Dr. Berghofer's plan of action. Stmt. of Material Facts ¶ 18. On December 12, 1995, Dr. Berghofer informed Nyhart that Parker's lab tests for chest x-ray and pulmonary function were "normal," and enclosed the requested medical records. Id. ¶ 19.
On December 22, 1995 ELSA forwarded a memorandum to Nyhart that outlined Parker's primary job duties. Id. ¶ 20. That same day, Nyhart submitted all accumulated records from Dr. Berghofer, together with ELSA's description of Parker's work duties, to Individualized Care Management, Inc. ("ICM"), an outside independent physician peer review. Id. ¶ 21. On January 2, 1996, Dr. Martin J. Maassen of ICM wrote Nyhart indicating that he saw "no reason for disability after November 12, 1995," and questioned the medical records that had been submitted. This document was faxed to Nyhart no later than January 5, 1996 and was received by mail on January 9, 1996. Id. ¶ 22. Because the information submitted by Parker and her physician demonstrated normal pulmonary function results, because the Plan had determined that Parker's work environment did not contain excessive fumes or dust and met or exceeded all OSHA standards, and because an independent outside medical review of Parker's records indicated no justification for continued disability after November 12, 1995, the Plan preliminarily determined that Parker did not satisfy the definition of "total disability" after November 12, 1995. On January 5, 1996, Nyhart sent a letter to Parker notifying her of this preliminary determination and inviting her to submit any new or additional supporting medical documentation to support the claim. Id. ¶ 23.
In a January 17, 1996 letter Dr. Berghofer voiced his disagreement with the Plan's determination. Dr. Berghofer indicated that he had referred Parker to Dr. Mary Compton for further evaluation of her gastroesophageal reflux. Id. ¶ 24. On February 8, 1996, Nyhart wrote Dr. Compton requesting additional information regarding Parker's condition. Nyhart provided Dr. Compton with the Plan's definition of "total disability" and a description of Parker's work environment. Id. ¶ 25. That same day, Nyhart sent ICM additional documentation to review, including a consultation report from Dr. Doli Biondillo, the January 17, 1996 letter from Dr. Berghofer, and some miscellaneous office records from Dr. Berghofer. Id. ¶ 26.
On February 16, 1996, Dr. Compton indicated to Nyhart that she was not giving Parker a disability diagnosis, and that she had not told her to be off work. Id. at ¶ 27. Nyhart documented this conversation by making notes on its February 8, 1996 letter to Dr. Compton. Id.
Parker argues that this annotated letter regarding Nyhart's conversation with Compton is hearsay and should be disregarded. Because it does not appear that the document is offered for the truth of the matter asserted, however, it is not hearsay and may be considered.
Nyhart faxed a copy of the annotated February 8, 1996 letter to Dr. Maassen at ICM on February 16, 1996. Id. ¶ 28. ICM, which had been considering the additional information supplied by Dr. Berghofer and Dr. Biondillo, again recommended denial of the claim on February 27, 1996. ICM indicated "there is no additional information which supports any medical necessity for disability." Id. ¶ 29. The next day, Nyhart advised Parker in writing that the additional information provided by Dr. Berghofer and Dr. Compton had been reviewed, and again advised Parker that no additional disability benefits were available. Id. ¶ 30. Parker and her physicians continued to submit additional records over the course of March and early April 1996. One of the reports from Dr. Biondillo indicated possible "reactive airways dysfunction syndrome," but did not state that Parker was totally disabled. Id. ¶ 31. On April 12, 1996, Nyhart wrote Parker again, indicating the receipt of the letter from Dr. Biondillo, noting that he had not disabled her or provided any supporting medical documentation for continued disability, and advising that no additional benefits were available. Id. ¶ 32.
Between March and July 24, 1996, Nyhart continued to accumulate additional medical information regarding Parker, including a worker's compensation claim file which contained several extensive evaluation reports by Dr. Stephen Smith. Nyhart also collected documentation from Dr. Strawbridge, Dr. Biondillo, Dr. Berghofer, and others. Id. ¶ 33. In a pulmonary consultation on March 11, 1996, Dr. Strawbridge examined Parker and determined that it was hard for him "to tell whether she is disabled from her respiratory complaints. She insists she is." Id. ¶ 34.
After learning that Parker was not subject to excessive dust, weld fumes, or weld smoke at ELSA, and that her work area was clean and exceeded OSHA clean air requirements, Dr. Biondillo wrote in a May 1, 1996 letter: "I believe this would be adequate for her [Parker] to perform her job." He further stated that, "In my opinion she is not totally disabled from her reactive airways dysfunction syndrome." Dr. Biondillo had obtained a second opinion from Dr. Frederick. Finally, Dr. Biondillo noted, "Again, I do not believe Ms. Cheryl Parker qualifies as being totally disabled and as such she potentially may return to her previous activities at Subaru." Id. ¶ 35.
On April 26, 1996, Dr. Steven Smith — a specialist in Occupational and Environmental Medicine — conducted a Special Occupational and Environmental Medical Examination. His report noted that Parker brought x-rays with her which included radiographs of her chest taken in October and December 1995. The studies revealed "no evidence of any pulmonary infiltrates, pleural effusion, or any other evidence of intrinsic pulmonary disease." In addition, Dr. Smith determined: "I am not persuaded at this time that Ms. Parker's symptom complex is likely to be causally related to any putative exposure to paint vapors or welding fumes/gases in conjunction with her work activities at ELSA. The clinical syndrome is not typical of occupational asthma or of reactive Airways dysfunction syndrome." Id. ¶ 36.
On May 8, 1996, Dr. Smith conducted a follow-up visit with Parker. He noted: "I am hard pressed to identify any condition that should cause Ms. Parker to be disabled from resuming her work activities at ELSA Corporation at this point in time. . . . As a practical matter, at this point I do not feel that Ms. Parker has any occupational condition that should interfere with her ability to resume some work activities at this time." Id. ¶ 37. In a May 10, 1996 addendum to his report, Dr. Smith noted: "Today I called Dr. Shapiro, the pulmonologist who has most recently seen Ms. Parker, and I explained to him all of our findings and the paucity of evidence of any substantial amount of residual airways disease on our examinations. In addition, I informed Dr. Shapiro that all of the industrial hygiene data are unremarkable and that these data indicate that there were/are no significant exposures to any pulmonary irritants or toxins in the are[a] of the ELSA plant where Ms. Parker previously worked." Dr. Smith also noted: "[F]rom the standpoint of any putative occupational or environmental conditions, that Ms. Parker could resume her work activities at ELSA Corporation." Id. ¶ 38. Dr. Smith further noted a discrepancy between the information provided by Parker to her doctors regarding the onset of her alleged illness. When informing Dr. Shapiro of the results of his examination, "Dr. Shapiro stated that it was his recollection (he did not have the chart at the time) that Ms. Parker had a specific incident of significant exposure that had caused her problem. I informed Dr. Shapiro that was not the history that Ms. Parker had provided to me." Id. ¶ 39.
On June 5, 1996, Dr. Strawbridge noted in a pulmonary follow-up: "From a practical standpoint I think it's important that we test her ability to resume her normal lifestyle, that being return to work. I have written a note that she can return to work but I have also indicated that prudence would dictate that she should perhaps start ½ days and that every effort be made to avoid any potential respiratory irritants." Id. ¶ 40.
On July 24, 1996, Nyhart sent all accumulated medical records from the beginning of the claim, including the worker's compensation file and evaluations of Dr. Smith; records submitted by Dr. Berghofer, Dr. Strawbridge, Dr. Frederick, and Dr. Shapiro; a copy of the ELSA Corporation Employee Benefit Plan; the definition of total disability from the Plan booklet; and the prior physician peer reviews to the Medical Review Institute in Salt Lake City, Utah for an additional outside independent physician peer review. Id. ¶ 41. On July 31, 1996, Parker's attorney wrote Nyhart and formally requested an appeal of the denial of short-term disability benefits to Parker. Id. ¶ 42. On August 19, 1996 Nyhart received a faxed report from Medical Review Institute finding that there was no objective evidence of disability in the patient after November 12, 1995. Id. ¶ 43. Based on all records submitted, the two previous independent physician reviews, and the review by the Medical Institute Review, the Plan made a final denial of Parker's short-term disability claim and so advised her by letter dated August 20, 1996. Id. ¶ 44.
Parker now challenges that decision, claiming that the Plan wrongfully denied her benefits after November 12, 1995. The parties have fully briefed defendants' motion for summary judgment, which is now ripe for ruling.
II. STANDARDS A. SUMMARY JUDGMENT STANDARDS
As stated by the Supreme Court, summary judgment is not a disfavored procedural shortcut, but rather is an integral part of the federal rules as a whole, which are designed to secure the just, speedy, and inexpensive determination of every action. Celotex Corp. v. Catrett, 477 U.S. 317, 327 (1986); see United Ass'n of Black Landscapers v. City of Milwaukee, 916 F.2d 1261, 1267-68 (7th Cir. 1990), cert. denied, 111 S.Ct. 1317 (1991). Motions for summary judgment are governed by Rule 56(c) of the Federal Rules of Civil Procedure, which provides in relevant part:
The judgment sought shall be rendered forthwith if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law.
Once a party has made a properly-supported motion for summary judgment, the opposing party may not simply rest upon the pleadings but must instead submit evidentiary materials which "set forth specific facts showing that there is a genuine issue for trial." Fed.R.Civ.P. 56(e). A genuine issue of material fact exists whenever "there is sufficient evidence favoring the nonmoving party for a jury to return a verdict for that party." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249 (1986). The nonmoving party bears the burden of demonstrating that such a genuine issue of material fact exists. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586-87 (1986); Oliver v. Oshkosh Truck Corp., 96 F.3d 992, 997 (7th Cir. 1996), cert. denied, 520 U.S. 1116 (1997). It is not the duty of the Court to scour the record in search of evidence to defeat a motion for summary judgment; rather, the nonmoving party bears the responsibility of identifying the evidence upon which he relies. Bombard v. Fort Wayne Newspapers, Inc., 92 F.3d 560, 562 (7th Cir. 1996). When the moving party has met the standard of Rule 56, summary judgment is mandatory. Celotex, 477 U.S. at 322-23; Shields Enters., Inc. v. First Chicago Corp., 975 F.2d 1290, 1294 (7th Cir. 1992).
In evaluating a motion for summary judgment, a Court should draw all reasonable inferences from undisputed facts in favor of the nonmoving party and should view the disputed evidence in the light most favorable to the nonmoving party. Estate of Cole v. Fromm, 94 F.3d 254, 257 (7th Cir. 1996), cert. denied, 519 U.S. 1109 (1997). The mere existence of a factual dispute, by itself, is not sufficient to bar summary judgment. Only factual disputes that might affect the outcome of the suit in light of the substantive law will preclude summary judgment. Anderson, 477 U.S. at 248; JPM Inc. v. John Deere Indus. Equip. Co., 94 F.3d 270, 273 (7th Cir. 1996). Irrelevant or unnecessary facts do not deter summary judgment — even when in dispute. Clifton v. Schafer, 969 F.2d 278, 281 (7th Cir. 1992). "If the nonmoving party fails to establish the existence of an element essential to his case, one on which he would bear the burden of proof at trial, summary judgment must be granted to the moving party." Ortiz v. John O. Butler Co., 94 F.3d 1121, 1124 (7th Cir. 1996), cert. denied, 519 U.S. 1115 (1997).
B. STANDARD OF REVIEW UNDER ERISA
In Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989), the Supreme Court held that "a denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Where the plan gives the administrator discretion to interpret the plan terms or determine benefit eligibility, however, courts review the denial of benefit claims using the arbitrary and capricious standard. Carr v. Gates Health Care Plan, 195 F.3d 292, 294 (7th Cir. 1999), cert. denied 120 S.Ct. 1675 (2000). Under that standard, the administrator's decision will only be overturned if it is "downright unreasonable." Id. A denial of benefits will not be set aside if the denial was based upon a reasonable interpretation of the plan documents. If the administrator makes an informed judgment and articulates an explanation for it that is satisfactory in light of the relevant facts, then the administrator's decision is final. Id. Under the arbitrary and capricious standard, it is not the Court's function to decide whether it would reach the same conclusion as the plan or even rely on the same authority. Instead, the Court is only to determine if the decision was downright unreasonable. Id.
In making its decision, the Court must consider several factors, including "the impartiality of the decisionmaking body, the complexity of issues, the process afforded the parties, the extent to which the decision makers utilized the assistance of experts where necessary, and finally the soundness of the fiduciary's ratiocination." Hughes v. Life Ins. Co. of North America, 2000 WL 1269337 (S.D.Ind. September 5, 2000). Accord, Carr, 195 F.3d at 295; Chalmers v. Quaker Oats Co., 61 F.3d 1340, 1344 (7th Cir. 1995). Before concluding that a decision was arbitrary and capricious, a Court must be very confident that the decisionmaker overlooked something important or seriously erred in appreciating the significance of evidence. Hightshue v. AIG Life Ins. Co., 939 F. Supp. 1350, 1356 (S.D.Ind. 1996), aff'd. 135 F.3d 1144 (7th Cir. 1998).
III. DISCUSSION A. THE PROPER STANDARD OF REVIEW OF PARKER'S CLAIM
This first issue the Court must consider is the proper standard of review of the administrator's decision. While the default standard of review of such decisions is de novo, the Court uses an arbitrary and capricious standard when the Plan gives the administrator discretion to interpret its terms.
In this case, the Plan itself provides that the administrator has the power and duty to do all things necessary or convenient to effect the intent and purposes of the Plan, including construing the Plan, which construction shall be final and binding; correcting any defect, supplying any omission, or reconciling any inconsistency in the Plan in such manner and to such extent as it shall deem expedient to effectuate the Plan; and determining all questions that may arise under the Plan, including questions of eligibility to participate in the Plan and the benefits provided by the Plan. Stmt. of Material Facts ¶ 8. Parker admits that this language likely grants the administrator discretion and would require the Court to review its decision under the arbitrary and capricious standard. See Parker's Opposition Brief at p. 4. Parker's concession is not surprising given the fact that other Courts have found similar language sufficient to confer discretion on the administrator. See Neurological Resources, P.C. v. Anthem Insurance Companies, 61 F. Supp.2d 840, 852 (S.D.Ind. 1999) (applying arbitrary and capricious standard of review where Plan stated that administrator "has the responsibility to interpret and construe the provisions of the Plan" and "to determine eligibility to participate in the Plan"), citing Chojnacki v. Georgia-Pacific Corp., 108 F.3d 810, 814-815 (7th Cir. 1997) (concluding the deferential review should apply where plan language asserted that administrator is "responsible for interpreting provisions of this Plan"); Gallo v. Amoco Corp., 102 F.3d 918, 921 (7th Cir. 1996), cert. denied 521 U.S. 1129 (1997) (concluding that decisions of administrator who possessed "the discretion to interpret" a plan were entitled to deferential review).
Parker argues that the language of the SPD conflicts with the Plan, thereby stripping the administrator of such discretion. This argument is without merit. The SPD provides that the administrator ". . . . has the power and duty to do all things necessary to carry out the intent and purposes of the Plan, including interpreting the Plan." Gayle Kinnett Affidavit, Ex. 2. Thus, the SPD clearly gives the administrator the authority to "interpret" the Plan, which is consistent with the Plan's language giving the administrator authority to "construe" the Plan. Indeed, the word "construe" has been defined as follows: "To ascertain the meaning of language by a process of arrangement, interpretation, and reference." black's law dictionary 315 (6th ed. 1990). The Seventh Circuit has also noted that the terms "interpret" and "construe" are often used synonymously. Chojnacki, 108 F.3d at 815. Accordingly, there is no conflict between the language in the SPD and the language in the Plan.
Relying upon the Seventh Circuit's recent decision in Herzberger v. Standard Ins. Co., 205 F.3d 327 (7th Cir. 2000), Parker argues that the SPD's language "exactly tracks the language that Judge Posner stated is not sufficient to vest discretionary authority in the administrator." Parker's Opposition Brief at p. 3. The Court disagrees. The issue in Herzberger was whether "language in plan documents to the effect that benefits shall be paid when the plan administrator upon proof (or satisfactory proof) determines that the applicant is entitled to them confers upon the administrator a power of discretionary judgment. . . ." Id. at 329. The Court held that such language did not confer such discretion to the administrator. While the opinion did set out "safe harbor" language that plans could utilize to ensure such discretion, it did not mandate the use of that language. Instead, it found it sufficient for the "the plan [to] contain language that, while not so clear as our `safe harbor' proposal, indicates with the requisite if minimum clarity that a discretionary determination is envisaged." Id. at 331.
In this case, the Plan specifically gave the administrator the authority to interpret and construe its terms. While this language does not exactly mirror the "safe harbor" language in Herzberger, the Court finds it sufficient to command deferential review. Accordingly, because both the Plan and the SPD grant the administrator discretion to interpret and construe the terms of the Plan, the Court will consider the administrator's decision under the arbitrary and capricious standard of review.
B. NYHART'S INVESTIGATION OF PARKER'S CLAIM
The Court must determine whether the Plan's denial of Parker's claim was arbitrary and capricious. As previously noted, Dr. Berghofer had diagnosed Parker in October 1995 with chest wall syndrome and bronchitis and found her to be disabled for one month. The Plan initially approved Parker's disability claim for one month. Parker returned to Dr. Berghofer in November 1995, however, and he again took her off work due to a diagnosis of chest wall syndrome and gastroesophageal reflux disease ("GERD"). Dr. Berghofer noted that Parker experienced increased chest pain when exposed to dust and strong fumes in the workplace, or after prolonged sitting, lifting, or exertion. As a result, he concluded that Parker "remains unable to perform each of her duties of her regular position, and qualifies as totally disabled as a result of sickness."
Nyhart subsequently submitted all of Parker's medical records and a copy of her job description to ICM for an independent physician review. On January 2, 1996, Dr. Martin J. Maassen of ICM concluded that based upon the documentation submitted, there was no basis for finding Parker totally disabled after November 12, 1995. As Parker points out, there is no indication in the record of Dr. Maassen's area of specialty, if any. In any event, as a result of his report Nyhart notified Parker on January 5, 1996 that she would not receive disability benefits after November 12, 1995. Nyhart allowed Parker an opportunity to submit any new or additional supporting medical documentation to support her claim.
During the next month, Nyhart collected additional medical information from Parker's health care providers and submitted it to ICM for review. After reviewing the additional information, ICM concluded on February 27, 1996 that the additional information did not support any medical necessity for disability and recommended denial of the claim. Nyhart once again notified Parker that the additional information had been reviewed and that it was denying her claim for continued benefits.
From March to July 1996, Nyhart collected additional medical information on Parker. For example, it gathered a worker's compensation claims file that contained several evaluation reports from Dr. Stephen Smith. It also collected additional documentation from at least three other physicians. Finally, on July 24, 1996, Nyhart sent its entire file to the Medical Review Institute in Salt Lake City, Utah for an additional independent physician peer review. The physician providing the review was certified by the American Board of Internal Medicine and by the subspecialty boards of Internal Medicine in Pulmonary Disease and Addiction Medicine. The reviewer had been in practice since 1963; was an Associate Clinical Professor of Medicine at a college of medicine; was a Fellow of the American College of Chest Physicians; and a member of the American Society of Internal Medicine. Based upon a review of all the medical information, including Dr. Berghofer's records, the Plan's definition of "total disability," and Parker's job description, the independent physician noted:
Based on the submitted records, the patient had chest wall pains and mild esophagitis. The patient's anxiety should have been reassured and treated. Instead, the patient was seen by multiple consultants, and multiple tests were done due to iatrogenic overdiagnosis, and the patient was advised by SB, M.D. not to return to work for one month.
The evaluation of the patient by SS, M.D. noted in his letters dated 4/26/96 and 5/8/96 state that SS, M.D. found no objective evidence of disability in the patient. RHS, MD's agreement that he also felt that the patient was not truly disabled is noted in the second page of his 6/5/96 note, along with the concluding paragraph of the third page of this note. In my opinion, based on the submitted records, SB, MD's conclusions by 6/96 were not justified. Tolliver Aff., Ex. 24.
In sum, the physician concluded that there "is no objective evidence of disability in the patient after 11/12/95. The patient was not disabled after 11/12/95 because of chest or abdominal disease. Therefore, in my opinion, based upon the submitted records, the patient is not disabled after 11/12/95." After receiving this report, the Plan notified Parker by letter on August 24, 1996 that it had made a final denial of her claim. Stmt. of Facts ¶ 44.
C. PARKER'S ARGUMENTS
Parker's primary argument is that the Plan ignored Dr. Berghofer's and other physicians' statements and instead relied upon the opinions of two independent physicians. The arbitrary and capricious standard, however, does not allow the Court to second guess medical opinions. Instead, it must simply determine whether the Plan was arbitrary and capricious in relying upon a medical opinion. Parker argues that the first independent physician's opinion was absurd and that there was no indication of Dr. Maassen's speciality, if any. If the Plan had merely relied upon this first opinion, Parker's claim would be more persuasive.
Parker submitted that Dr. Maassen's opinion was absurd because he asked whether there was a union at ELSA, whether the company had a company doctor, and other questions that Parker found to be irrelevant to her condition. Parker believes the doctor submitted a form letter based upon diagnosis of a soft tissue injury and not a letter tailored to Parker's medical condition.
Instead, after it denied Parker continued benefits, the Plan gathered additional medical information on her condition and eventually submitted it to yet another independent physician review panel. The physician performing this review had been in practice since 1963 and was certified by the American Board of Internal Medicine and by the subspecialty boards of Internal Medicine in Pulmonary Disease and Addiction Medicine. After reviewing all of the medical records, the Plan's definition of "total disability," and Parker's job description, the physician concluded that there was no objective evidence that Parker was disabled after November 12, 1995. Based upon this second independent evaluation of Parker's medical condition, the Plan denied her claim for continued benefits.
In sum, the Plan's decision simply came down to a choice between the conclusion of the Medical Review Institute — an independent medical consultant — and the conclusion of Parker's physicians. The Seventh Circuit and other courts have recognized that reliance upon an independent medical expert's opinion is a permissible basis for denying claims. See Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 380 (7th Cir. 1994) (". . . we must conclude that MetLife's determination to deny Ms. Donato benefits was not unreasonable. MetLife's decision simply came down to a permissible choice between the position of UMAC, MetLife's independent medical consultant, and the position of Ms. Donato's clinical ecologists"); Ramos v. Metropolitan Life Ins. Co., 1995 WL 46715, *4 (N.D.Ind. January 24, 1995), aff'd. 61 F.3d 906 (7th Cir. 1995) (finding that defendant had not acted in arbitrary and capricious manner and its denial of benefits was reasonable where it relied on an independent medical consultant's opinion).
D. THE FIVE-FACTOR ARBITRARY AND CAPRICIOUS TEST
As noted earlier, the arbitrary and capricious standard requires the Court to conduct a "deferential" review of the decision maker's action. Hightshue, 939 F. Supp. at 1356. In addition, the Seventh Circuit requires the Court to consider "the impartiality of the decisionmaking body, the complexity of issues, the process afforded the parties, the extent to which the decision makers utilized the assistance of experts where necessary, and finally the soundness of the fiduciary's ratiocination." Hughes, 2000 WL 1269337. Finally, before concluding that a decision was arbitrary and capricious, the Court must be very confident that the decisionmaker overlooked something important or seriously erred in appreciating the significance of evidence.
Parker does not argue that there was a conflict of interest present in this case. The Court will assume that the fiduciary acted in a neutral manner unless the claimant can show through specific evidence of "actual bias" that there was a significant conflict. Id. Because Parker presented no evidence of a conflict, the Court will presume that none existed.
The second factor does not assist either party. While the question of whether Parker's medical condition caused her to be "totally disabled" as defined by the Plan may have involved complex medical issues, there is nothing in the record to suggest that the issue was so complex as to render the Plan's decision arbitrary and capricious.
The third factor — the process afforded the parties — weighs in favor of Nyhart and the Plan. Indeed, Nyhart appears to have thoroughly investigated Parker's claim. After gathering and reviewing medical records from numerous health care providers, it provided that information to two different independent physician review panels. Nyhart allowed Parker opportunities to submit additional materials in support of her claim, and kept her informed of developments in her case. Taken as a whole, it appears that the investigatory process was neither arbitrary nor capricious.
The fourth factor considers the Plan's use of outside experts. As discussed, Nyhart submitted all of Parker's medical information to two different independent physician review panels. There is no evidence in the record of the credentials the first independent physician, Dr. Maassen. It is undisputed, however, that the Plan also utilized the Medical Review Institute to provide a second independent review of Parker's claim. The Court has already discussed the credentials of the physician that provided that review and that physician's analysis and conclusions. The use of the Medical Review Institute as an independent outside expert weighs in favor of the Plan.
The final factor requires the Court to consider the Plan's reasoning. According to the August 20, 1996 letter denying Parker's claim, the Plan relied upon the Medical Review Institute's determination that there was no objective evidence of disability after November 12, 1995, and that neither Parker's chest condition nor her abdominal disease rendered her disabled. The Court believes this is a sound reason for the Plan to deny Parker's claim.
In sum, after reviewing the five factors above, the Court concludes that the Plan's decision was neither arbitrary nor capricious. It provided sufficient process to Parker and ultimately relied upon an independent physician's review of her claim in making its final decision. The Plan was simply faced with choosing between conflicting medical opinions — one from the Medical Review Institute and the others from Parker's physicians — regarding whether Parker's medical condition rendered her totally disabled. The Court cannot weigh the merits of those opinions. Instead, it must simply decide whether the Plan's decision to rely on the opinion of the Medical Review Institute was arbitrary and capricious. In this case, the Court cannot conclude that the Plan "overlooked something important or seriously erred in appreciating the significance of the evidence." Hightshue, 939 F. Supp. at 1363. Because the Plan's decision was not arbitrary and capricious, defendants are entitled to summary judgment on Parker's claim.
III. CONCLUSION
Parker has failed to present sufficient evidence from which the Court could find a genuine issue of material fact on her ERISA claim. Accordingly, defendants' motion for summary judgment is GRANTED.